Manatee Springs Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bradenton, Florida.
- Location
- 5627 9th St E, Bradenton, Florida 34203
- CMS Provider Number
- 105525
- Inspections on file
- 18
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 3 (3 serious)
Citation history
Health deficiencies cited at Manatee Springs Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with advanced dementia, severe cognitive impairment (BIMS 6), wandering, impulsivity, agitation, muscle weakness, and high elopement and fall risk exited through an alarmed stairwell door after leaning on it, triggering an audible alarm and message. The supervising LPN, unable to recall the alarm code, assumed the alarm was malfunctioning, called maintenance, and returned to other tasks without initiating an elopement response or head count. The assigned CNA was on break, believed the alarm was another malfunction, and did not re-check the resident on return, while the assigned LPN heard an unfamiliar alarm but did not immediately verify resident whereabouts and reported no prior elopement drill training. No staff responded effectively to the alarm, allowing the resident to descend two flights of stairs, exit a second alarmed door, walk through the parking lot and across a four-lane road, and enter a neighborhood where he fell, sustaining a forehead laceration and elbow skin tear, and was later found outside in the rain by law enforcement and transported to the hospital; the facility remained unaware of his absence until notified by police, and Immediate Jeopardy was cited for neglect and failure to prevent elopement.
A severely cognitively impaired resident with dementia, psychotic features, high fall risk, and documented elopement risk exited the facility after staff failed to respond appropriately to two sounding exit door alarms. The resident, who required supervision and CGA for mobility due to poor safety awareness, was last seen in bed by a CNA who then went on break. When the stairwell door alarm activated, the supervising LPN went to the wrong door, could not recall the alarm code, assumed a malfunction, and called maintenance instead of initiating the elopement protocol or a code purple. Another LPN heard the alarm but was told it was malfunctioning and did not start a search or head count, and the CNA did not re-check residents on return from break, believing it was another malfunction like a prior event. Video later showed the resident walking down the therapy hall, triggering the stairwell alarm, descending two flights of stairs, and exiting through a back door with a second alarm, after which he walked through the parking lot, crossed a four-lane road, and entered a neighborhood where law enforcement found him wet, shivering, and injured from a fall, leading to EMS transport to the hospital.
A resident with advanced dementia, severe cognitive impairment, high elopement and fall risk, and documented wandering and impulsive behaviors exited through an alarmed stairwell door after walking past the nurse’s station and down a hallway. The exit door alarms on both the second and first floors sounded loudly, but the supervising LPN assumed the alarm was malfunctioning, went to the wrong door, could not recall the code to silence it, and contacted maintenance instead of initiating the elopement protocol. The assigned CNA was on break when the alarm activated, did not re-check the resident on return, and believed the alarm was another malfunction, while another LPN heard an unfamiliar alarm but did not recognize it as an exit alarm and reported never having completed elopement drills. Maintenance later confirmed the door system was functioning properly. No timely head count or search was conducted, and the resident walked off the premises, across a multi-lane road, and into a neighborhood, where law enforcement found the resident wet from rain, shivering, and injured from a fall, requiring EMS transport and hospital evaluation.
The facility failed to ensure that four nursing aides obtained their CNA certification within the required four months of hire, as mandated by Florida regulations. Despite being employed for over four months, Staff A, B, C, and D were not certified. Interviews with the Human Resources Director, DON, and NHA revealed a lack of awareness and oversight regarding the certification status of these aides, resulting in a violation of state regulations.
The facility failed to identify PTSD triggers and develop specific care plans for two residents with PTSD, leading to a deficiency in trauma-informed care. Despite receiving psychiatric services, there was no documentation of triggers or strategies to prevent re-traumatization. Staff interviews revealed a lack of awareness of the residents' PTSD triggers, and care plans lacked individualized interventions.
The facility failed to secure medications, with several residents having unsecured medications at their bedsides without proper self-administration orders. Additionally, a medication cart was left unlocked and unattended, violating facility policies on medication storage and security.
Three residents in an LTC facility did not receive a dignified dining experience due to staff inaction. One resident was unable to access her meal tray due to a locked wheelchair, while another waited 45 minutes for meal assistance. A third resident, dependent on staff for eating, was left unattended for a similar duration. Staff acknowledged the delays and lack of coordination, which violated the facility's dignity and respect policy.
The facility failed to maintain confidentiality of resident records, with incidents involving a resident's chart sticker visible in a common hallway and unlocked medication cart computer screens displaying resident information. Staff acknowledged the lapses, which contravened the facility's policy on safeguarding medical records.
The facility failed to complete PASARRs for residents with mental disorders and intellectual disabilities, affecting five residents. PASARRs for these residents either lacked necessary checks or did not follow up on recommendations for Level II assessments. Interviews revealed that the facility had no PASARR policy and had initiated revisions without evidence of completion.
A facility failed to monitor and maintain negative wound pressure therapy for a resident with necrotizing fasciitis, as the machine was not functioning and orders were not documented. Additionally, the facility did not ensure an upper extremity support wedge was ordered and monitored for a resident with arm paralysis, as there were no directions for staff and the care plan lacked relevant interventions.
Two residents with hemiplegia following strokes were not consistently provided with necessary splints to prevent decreased range of motion, despite having physician orders and care plans in place. Observations showed that splints were not applied as required, and interviews with staff revealed confusion about the responsibility for splint application. This lack of adherence to the facility's policy resulted in deficiencies in the care provided to these residents.
The facility failed to properly store and maintain respiratory equipment for residents, with nebulizer and CPAP masks found improperly stored or exposed. Additionally, tracheostomy care for a resident was not provided according to standards, with incomplete orders and lack of documentation for self-suctioning. Staff interviews confirmed the deficiencies, and facility policies on respiratory care were not followed.
An LPN failed to document the removal of a Norco tablet in the medication monitoring control record after administering it to a resident, leading to incomplete documentation. The facility's policy requires documentation in both the MAR and narcotic control sheet at the time of administration, which was not followed.
Failure to Respond to Exit Alarm and Supervise High-Risk Resident Resulting in Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from neglect by not responding appropriately to an exit door alarm and not providing adequate supervision to prevent elopement. The resident had diagnoses including dementia, psychotic disorder with hallucinations, depression, delusional disorder, falls, muscle weakness, and lack of coordination. A recent MDS showed a BIMS score of 6, indicating severe cognitive impairment, and progress notes documented wandering, impulsivity, agitation, difficulty with redirection, and concern for safety. The resident had been assessed as at risk for elopement, with an elopement risk score of 19 on admission (≥12 indicating risk) and a subsequent score of 10, and the care plan identified elopement risk related to cognitive impairment with interventions such as notifying other departments of elopement risk and using verbal cues and distraction techniques. On the night of the incident, the resident was last seen by the assigned CNA around 2:30 a.m. in bed asleep. Shortly thereafter, an emergency stairwell exit door alarm by the therapy department sounded. Video footage later reviewed by the Director of Plant Operations showed the resident, without a walker or wheelchair, walking down the therapy hallway holding the railing, leaning on the stairwell door at approximately 2:32 a.m., triggering the alarm and the audible message “Exit now, exit now,” and then opening and closing the door. The resident then descended two flights of stairs and exited the building through another alarmed door to the outside, all unwitnessed by staff. The stairwell and exterior areas had no cameras, and no staff were observed responding to the alarm during at least 20 minutes of reviewed footage. Multiple staff heard or were informed of the alarm but did not initiate the facility’s elopement procedures. The supervising LPN on duty, who was on the second floor when the alarm first sounded, attempted to silence the alarm but could not recall the code and assumed the alarm was malfunctioning. She contacted maintenance for assistance and then returned to other tasks on the first floor without initiating a search, checking outside, or calling a code for a head count. The assigned CNA was on break when the alarm sounded, received a call from the supervisor about the alarm, and believed it was another malfunction similar to a prior event; he did not check on his residents when he returned from break and recalled the alarm still sounding. The LPN assigned to the resident heard an unfamiliar alarm but did not recognize its source, did not immediately verify resident whereabouts, and reported not having been trained on elopement drills or the sound of the door alarms. Other staff on the first floor either did not hear the alarm or were told by the supervisor that it was a malfunction. During this time, the resident left the facility, walked through the parking lot, crossed a four-lane road, and entered a neighborhood where he fell, sustaining a left forehead laceration and left elbow skin tear, and was eventually found outside, wet and shivering in the rain, by local law enforcement and transported to the hospital. The facility did not become aware of the resident’s absence until notified by law enforcement, and the resident had been missing for approximately two hours without staff knowledge, leading surveyors to determine Immediate Jeopardy related to neglect and failure to prevent elopement. Interviews with clinical providers further underscored the resident’s known risks. The nurse practitioner and physician described the resident as having advanced dementia, confusion, cognitive dysfunction, impulsivity, restlessness, difficulty with redirection, shuffling gait, and muscle weakness, with a history of expressing a desire to go home and requiring assistance with ambulation using a walker. Staff nurses and CNAs reported that the resident frequently wandered, was extremely confused, constantly tried to get up, was unsteady on his feet, and required frequent redirection, with some staff stating he should have been on 1:1 supervision or 15-minute checks due to his behaviors and fall risk. Despite these known risks and the existing care plan identifying elopement risk, staff did not implement effective supervision or appropriate responses to the door alarm on the night of the incident, resulting in the resident’s unwitnessed elopement and injury.
Removal Plan
- Implemented 1:1 supervision with staff at all times for Resident #2 due to elopement risk.
- Implemented an order that Resident #2 may only go out on leave of absence (LOA) with a responsible party.
- Updated Resident #2 care plan to include family assisting with placement to a secured unit.
- Updated Resident #2 care plan to include providing the resident with a 1:1 companion as needed to decrease risk of exit seeking.
- Provided education to the assigned nursing supervisor and assigned nurse regarding responding to alarming doors, searching immediate surroundings, completing a head count when doors alarm, and timely DON notification of elopement.
- Suspended the nurse supervisor and assigned CNA pending investigation.
- Held an ad hoc QA meeting regarding elopement with the Administrator, DON, ADON, VP of Clinical Operations, and Medical Director.
- Conducted ongoing QAPI discussions focused on response to alarming doors, elopement drills, head counts, and prevention of neglect related to elopement.
- Provided education to the DON, ADON, and Administrator regarding the elopement, affected policies, alarming doors, head counts, risk management reports, reporting to AHCA, elopement drills/audits, QAPI, hourly head count, investigation guidance, and ongoing education/monitoring.
- In-serviced department heads on responding to alarming doors and checking surrounding areas to visually ensure the area is secure.
- Initiated abuse and neglect policy education with all current staff, emphasizing neglect, maintaining a safe environment, and required actions when a door alarm sounds.
- In-serviced assigned staff on responding to alarming doors, checking surrounding areas, performing a head count, and neglect/elopement prevention and response.
- Conducted elopement drills on every shift, then implemented random weekly drills performed by DON/ADON/designee.
- Started elopement education audits, then transitioned to random-shift audits performed by DON/ADON/designee.
- Completed elopement risk reassessments for all residents by ADON, clinical unit managers, and DON.
- Reviewed care plans for residents at risk for elopement by DON.
- Reviewed the elopement binder for accuracy by DON.
- Audited all current residents' LOA orders in the electronic health system by DON, ADON, and unit managers.
- Performed routine door monitor/alarm function checks at all exit doors by the Director of Maintenance.
- Tested exit alarms by a third-party independent contractor.
- Updated the CE-4 Elopement Prevention Policy; reviewed with the IDT in ad hoc QAPI and re-issued to all departments with education provisions.
- In-serviced current staff on the updated CE-4 Elopement Prevention Policy.
- Implemented emergency in-servicing education that all alarming doors must be treated as potential resident elopement and require a head count, and that only maintenance can identify a malfunctioning door alarm.
Failure to Respond to Exit Alarms Leads to Elopement and Injury of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to respond to two exit door alarms and provide adequate supervision to prevent a severely cognitively impaired, high fall- and elopement-risk resident from exiting the building. The resident had dementia with psychotic features and delusions, severe cognitive impairment with a BIMS score of 6, impaired decision-making, a documented determination of incapacitation, and multiple diagnoses including myasthenia gravis, atrial fibrillation on anticoagulation, depression, delusional disorder, and muscle weakness. Care plans and assessments identified the resident as at high risk for falls and at risk for elopement and wandering, with documented wandering, impulsivity, agitation, difficulty with redirection, and unsteadiness on his feet. Therapy notes showed he required supervision or touching assistance and contact guard assist for transfers and gait due to poor safety awareness and high fall risk. On the night of the incident, the resident was last seen around 2:30 a.m. in bed asleep by his assigned CNA. Shortly thereafter, an emergency stairwell exit door alarm by the therapy department on the second floor sounded. The supervisor LPN, who was on the second floor at the time but assigned to the first floor, went to the wrong door near the wound care nurse’s office, attempted to silence the alarm but could not recall the code, and assumed the alarm was malfunctioning. She contacted maintenance rather than initiating the facility’s elopement policy, which required calling a code purple, conducting an immediate search, checking outside, and completing a head count. Another LPN on the unit heard the alarm but was told by the supervisor that it was malfunctioning, and she did not initiate elopement procedures at that time. The assigned CNA was on break when the alarm sounded, received a call from the supervisor asking how to turn off the alarm, believed it was another malfunctioning door based on a similar prior event, and did not check on his residents when he returned from break, even though the alarm was still sounding. Video footage reviewed by the Director of Plant Operations showed the resident walking down the therapy hallway without a walker or wheelchair, holding onto the railing, leaning on the exit door, triggering the alarm at approximately 2:32 a.m., and then exiting through the stairwell. The resident proceeded down two flights of stairs to a first-floor exit door at the back of the facility, where a second alarm (a red screamer) sounded and later self-terminated after 10–15 minutes. Staff on the first floor reported they did not hear or see anything, and no staff were observed responding to the alarms on the video. The resident then walked approximately 170 yards through the back parking lot, crossed a four-lane road with a 40 mph speed limit, and entered a nearby neighborhood in rainy conditions. Local law enforcement was dispatched around 4:48 a.m. to a neighborhood residence for an elderly male with a head injury knocking on doors; officers identified him as the resident from the memory care unit. He was found soaking wet, shivering, and with a laceration to his left eyebrow and a skin tear to his left elbow from a fall, and EMS transported him to the hospital. EMS documentation indicated the fall occurred about two hours before assessment, and the resident had been missing from the facility for approximately two hours without staff knowledge. The facility’s failure to respond appropriately to the exit door alarms and to supervise the resident in accordance with his known fall and elopement risks resulted in his unwitnessed exit and subsequent injury, and surveyors determined this constituted Immediate Jeopardy.
Failure to Respond to Exit Door Alarms Leads to Resident Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff were knowledgeable and competent to respond appropriately to exit door alarms, resulting in an elopement. A resident with dementia and severe cognitive impairment, admitted with diagnoses including dementia with psychotic disturbance, depression, delusional disorder, falls, muscle weakness, lack of coordination, and hallucinations, had documented elopement risk. Elopement risk assessments showed scores at or above the facility’s threshold for exit-seeking and wandering, and progress notes described the resident as confused, disoriented, impulsive, wandering, agitated, and difficult to redirect. Therapy and provider documentation indicated the resident had a shuffling gait, muscle weakness, unsteadiness on feet, and required assistance and a walker for safe ambulation. Staff, including the MD and NP, described the resident as having advanced dementia, high risk for elopement and falls, and appropriate for a memory care setting. On the night of the incident, the resident was last seen in bed asleep around 2:30 a.m. by the assigned CNA. Shortly thereafter, the resident exited his room, walked down the hallway past the elevator and nurse’s station, and pushed on an alarmed stairwell exit door near the therapy gym. Video reviewed by the Director of Plant Operations showed the resident walking down the therapy hallway holding the handrail, leaning on the exit door, triggering the alarm, and then exiting through the door after the 15‑second delay while the alarm and audible message sounded. The resident then descended two flights of stairs and exited through another alarmed door on the first floor to the outside of the building. The alarms on both the second-floor and first-floor doors were described by multiple staff and maintenance as loud and audible in the nearby nurse’s station areas, with flashing lights indicating which door was alarming. Despite the alarms sounding, nursing staff did not initiate the facility’s elopement protocol. The supervising LPN on duty went to the wrong exit door, attempted to silence the alarm but could not recall the code, and assumed the alarm was malfunctioning. She contacted maintenance and communicated to other staff that the alarm was a malfunction, leading staff, including the assigned CNA and another RN, to believe it was not a true elopement event. No immediate head count, search of the building, or outside check was initiated at the time the alarm sounded. The assigned CNA was on break when the alarm activated, did not verify the resident’s presence upon returning, and recalled that the alarm continued to sound but did not prompt him to check his residents because he believed it was another malfunction similar to a prior event. Another LPN on the unit heard an unfamiliar alarm sound for a few minutes but did not recognize it as an exit alarm, did not know where it originated, and reported she had never completed elopement drills and was not familiar with the alarm sound. Maintenance staff arrived approximately 15–20 minutes after the initial alarm, found only the therapy hall stairwell door alarming, and successfully reset it, confirming there was no malfunction. First-floor staff reported not hearing the alarm unless they were near the specific door and did not become aware of the situation until law enforcement arrived. Law enforcement records indicated that the supervising LPN acknowledged receiving an open door alarm around 3:00 a.m. but “thought nothing of it, almost ignoring it,” and that no one was covering the watch role while a staff member was on break. The resident was found off premises by local police in a nearby neighborhood, wet from rain, shivering, and with a laceration above the left eyebrow and a skin tear on the left elbow after a fall. EMS documentation and emergency room records confirmed the resident had been missing from the facility for approximately two hours before being located and transported to the hospital for evaluation and treatment. The surveyors determined that staff’s failure to recognize and respond appropriately to the exit door alarms and to follow elopement procedures constituted a lack of competency in providing care and services to prevent elopement for this resident.
Failure to Ensure CNA Certification for Nursing Aides
Penalty
Summary
The facility failed to ensure that four nursing aides, identified as Staff A, B, C, and D, obtained their certified nursing assistant (CNA) certification within four months of their hire dates, as required by Florida regulations. Staff A was hired on June 18, 2024, Staff B and C on September 24, 2024, and Staff D on October 22, 2024. Despite being employed for over four months, none of these staff members had obtained their CNA certification. This deficiency was identified during a review of documentation provided by the Human Resources Director, which confirmed the lack of certification for these staff members. Interviews conducted with the Human Resources Director, the Director of Nurses (DON), and the Nursing Home Administrator (NHA) revealed a lack of awareness and oversight regarding the certification status of these nursing aides. The Human Resources Director confirmed the employment of uncertified nursing aides, while the DON was unaware of their certification status. The NHA acknowledged the requirement for nursing aides to obtain certification within four months of hire but was not aware that Staff A, B, C, and D were working beyond this period without certification. The facility's failure to comply with the certification requirement for nursing aides was a clear violation of the Florida Statutes governing nursing homes and related health care facilities.
Failure to Identify PTSD Triggers and Develop Care Plans
Penalty
Summary
The facility failed to accurately identify and document resident-specific triggers related to PTSD for two residents, leading to a deficiency in providing trauma-informed care. Resident #32, who has a history of PTSD, bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, was observed to be tearful and anxious, particularly in the mornings. Despite receiving psychiatric and psychological services, there was no documentation in her records identifying her PTSD triggers or strategies to prevent re-traumatization. Interviews with staff revealed a lack of awareness and understanding of her specific triggers, and the care plan did not include individualized interventions to address her PTSD. Similarly, Resident #56, who was diagnosed with chronic PTSD, major depressive disorder, mood disorder, and dementia, also lacked a comprehensive care plan addressing her PTSD. Although her records indicated a history of trauma, including being raped at 15, there was no documentation of her triggers or interventions to prevent re-traumatization. Interviews with staff, including the DON and LPN, showed a lack of awareness of her PTSD diagnosis and triggers, and her care plan did not reflect any specific strategies to address her condition. The facility's Trauma Informed Care policy emphasizes the importance of identifying triggers and providing individualized care to prevent re-traumatization. However, the facility did not adhere to these guidelines, as evidenced by the lack of documented triggers and individualized care plans for both residents. This deficiency highlights a failure to provide culturally competent, trauma-informed care as required by professional standards and the facility's own policies.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored securely and were inaccessible to unauthorized individuals, including staff, residents, and visitors. During a facility tour, it was observed that several residents had medications unsecured at their bedsides. Resident #24 had eye drops on the bedside table, which were not included in the self-administration orders, and the resident admitted to not keeping them in the lockable drawer as required. Similarly, Resident #111 had an inhaler/decongestant at the bedside without any physician orders for self-administration. Resident #58 had a medicated powder on a chair by the bedside, also without current orders for self-administration. Interviews with staff confirmed that all medications should be secured, and self-administration orders should be in place for residents to keep medications at their bedside. Additionally, Resident #34 was found to have an inhaler taped to the bed siderails, despite having self-administration orders. The facility's policy requires medications to be stored securely, even for residents with self-administration orders. The Director of Nursing and Assistant Director of Nursing acknowledged that medications should be secured at the bedside. The facility's policy on medication administration and storage emphasizes the need for secure storage and proper authorization for self-administration, which was not adhered to in these cases. Furthermore, a medication cart was left unlocked and unattended by Staff S, an LPN, outside the nurse's station, with resident information visible to others. This was a breach of the facility's policy, which mandates that medication carts and computers be locked when not in use and only accessible to authorized personnel. The facility's policies on medication storage and self-administration were not followed, leading to unsecured medications and potential access by unauthorized individuals.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during a survey. Resident #6 was observed in her room unable to access her lunch tray because her wheelchair was locked, and she required assistance to position herself and open meal containers. Despite having a care plan indicating the need for meal setup assistance, staff did not provide the necessary help in a timely manner, leaving the resident unable to eat independently. Resident #25 was found in bed with his meal tray at his bedside, waiting for assistance for approximately 45 minutes. The resident, who has a history of dementia and hemiplegia, was dependent on staff for meal assistance as per his care plan. Staff acknowledged the delay in providing assistance, which was contrary to the facility's procedure of preparing residents for meals and ensuring timely assistance. Resident #33 was also observed waiting for meal assistance while other residents had finished their meals. The resident, who has cognitive impairments and requires total assistance for eating, was left unattended for about 45 minutes. Staff interviews revealed a lack of coordination and communication among CNAs, resulting in the resident not receiving the necessary help. The facility's policy on dignity and respect was not adhered to, as residents were not treated with the expected level of care and assistance.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as evidenced by two specific incidents. In the first incident, a metered dose inhaler box with a resident's chart sticker was found in the medication cart trash, which was located in a common hallway visible to non-staff individuals. Interviews with staff revealed that protected health information (PHI) should be shredded before disposal, but this procedure was not followed in this case. In the second incident, two separate observations were made where medication cart computer screens were left unlocked and unattended, displaying residents' information to passersby. In both cases, the responsible LPNs acknowledged their failure to lock the computers and medication carts. The facility's policy mandates the protection and safeguarding of all medical records, but these incidents demonstrate a lapse in adherence to this policy.
Failure to Complete PASARRs for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with mental disorders and intellectual disabilities following qualifying mental health diagnoses. This deficiency was identified for five out of nine residents reviewed. For Resident #43, the PASARR dated 09/29/23 did not have the qualifying diagnoses checked, and recommendations for a Level II PASARR were not acted upon. Similarly, Resident #18's PASARR dated 04/29/24 also lacked the necessary checks and follow-up actions. Resident #24's PASARR from 08/26/19 showed the same oversight, with no action taken on the recommendations for a Level II PASARR. Interviews with the Regional Nurse Consultant (RNC) and Director of Nursing (DON) revealed that the facility had initiated revising the PASARRs but lacked evidence of completion, and they did not have a PASARR policy in place. Resident #31 was admitted with diagnoses including psychotic disorder and bipolar disorder, but the PASARR dated 5/6/24 did not require a Level II assessment despite the presence of qualifying mental health diagnoses. The DON confirmed that the resident did not have a diagnosis of anxiety, which was incorrectly noted on the PASARR. Resident #56's PASARR dated 7/14/22 recommended a Level II assessment due to depressive disorder, but a subsequent PASARR dated 7/27/23 did not reflect any mental illness diagnoses, and no Level II assessment was completed. The DON confirmed the inaccuracies in Resident #56's PASARR and the lack of a Level II assessment.
Deficiencies in Wound Care and Positioning Device Monitoring
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of negative wound pressure therapy for a resident with necrotizing fasciitis and Fournier gangrene. The resident's negative pressure wound machine was observed not functioning, with tubing hanging on the floor, and the resident reported that the machine caused pain and frequently detached. Despite having orders for negative pressure wound therapy dressing changes and specific settings, the orders were not properly documented in the resident's medical record. The Director of Nursing confirmed the lack of documentation, and staff had difficulty contacting the resident's wound care doctor. Additionally, the facility did not ensure that an upper extremity elevation support wedge was ordered and monitored for a resident with left arm paralysis due to a motor vehicle accident. The resident was observed with his arm not properly positioned on the support wedge, and there were no directions for the nursing staff regarding the application of positioning devices. The resident's care plan did not include any focus, goal, or interventions related to positioning devices, and the therapy department had not evaluated the resident since a hospitalization in 2023. Interviews with staff revealed that the facility's policy required PT and OT to evaluate residents for positioning devices, but the resident's girlfriend had brought the support device to the facility, and CNAs continued to use it without formal orders. The facility's policy on consultants and care planning emphasized the need for proper documentation and physician orders for any recommendations, which were not followed in this case.
Failure to Apply Splints for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that splints were applied to prevent the decrease of range of motion for two residents. Resident #50, who has a history of hemiplegia following a stroke, was observed multiple times without splints or rolls in her hands, despite having physician orders for a right palm roll or washcloth roll every shift. The resident expressed that staff did not frequently apply the splints, and she often forgot to request them. The care plan indicated the need for a towel roll in the right hand for skin integrity, but observations showed that this was not consistently implemented. Resident #88, also diagnosed with hemiplegia following a stroke, was similarly affected. The resident's care plan included a right resting hand splint to be worn from morning to evening or as tolerated every shift. However, interviews with staff revealed confusion about the responsibility for applying the splints, with CNAs and restorative staff each believing it was the other's duty. This lack of clarity resulted in the resident not consistently receiving the necessary splinting care. Interviews with various staff members, including CNAs, LPNs, and the Director of Nursing, highlighted a disconnect between the facility's policy and the actual practice regarding splint application. The facility's policy stated that nursing staff were responsible for applying splints based on a schedule established after assessment, but this was not adhered to. The Director of Rehabilitation confirmed that therapy screened residents quarterly for contracture management, but the responsibility for daily splint application was not clearly communicated or executed, leading to the observed deficiencies.
Deficiencies in Respiratory Equipment Storage and Tracheostomy Care
Penalty
Summary
The facility failed to ensure proper storage and maintenance of respiratory equipment for residents on one of its floors. Observations revealed that a resident's nebulizer mask was left exposed on a nightstand without proper labeling or dating of the tubing, contrary to physician orders requiring weekly changes and labeling. Another resident's CPAP mask was found detached and with its hose on the floor, while a third resident's nebulizer mask was improperly stored in a drawer without a bag. Interviews with staff confirmed that the equipment should be cleaned, stored in a dated bag, and not left on the floor or improperly stored. Additionally, the facility did not provide tracheostomy care and suctioning according to standards for a resident with a tracheostomy tube. The resident was observed with a tracheostomy tube without visible ties and gauze surrounding it. The resident reported being able to self-suction, but there was no documentation of education on suctioning in the medical record. The resident's orders were incomplete, lacking specifics on trach size and self-suctioning, and the oxygen was set at a different rate than ordered. Interviews with staff, including the Director of Nursing, acknowledged the incomplete orders and lack of documentation. The facility's policies on respiratory equipment and tracheostomy care were not adhered to, as evidenced by the improper storage of equipment and incomplete tracheostomy orders. The facility's policy required nebulizer equipment to be stored in a bag and tracheostomy care to be performed at least twice daily, with specific orders for care and treatment. The failure to follow these policies and physician orders contributed to the deficiencies observed during the survey.
Incomplete Documentation of Narcotic Administration
Penalty
Summary
The facility failed to ensure complete documentation of narcotic removal, which is crucial for identifying loss or potential diversion of controlled medications. During a medication administration observation, an LPN removed and administered a Norco tablet to a resident but did not document the removal in the medication monitoring control record before proceeding to administer medications to another resident. This lapse in documentation was identified when a review of the resident's Medication Monitoring Control Record showed missing information, specifically the name of the person administering the medication. The Director of Nursing confirmed that the facility's expectation is for staff to document the removal of narcotics in the control record at the time of administration. The facility's policy on medication administration, last reviewed in September 2022, mandates that licensed personnel must document the administration of narcotics in both the Medication Administration Record and the narcotic control substance sheet at the time of administration. The LPN acknowledged forgetting to sign their name, which contributed to the incomplete documentation.
Latest citations in Florida
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to comply with NFPA 99, NFPA 70, and NFPA 1 requirements for electrical equipment when, during a tour with the Maintenance Director, a power strip in the electrical room was observed being used as a permanent power source instead of a dedicated receptacle. The report states that this improper use of a relocatable power tap could lead to electrical hazards for residents and staff, and notes that extension cords and power strips are not to be used as substitutes for fixed wiring under the cited codes.
Surveyors found that the facility did not have documentation showing completion of the required annual 90‑minute test of emergency lighting. During record review and interview, the Director of Facilities confirmed that records of this annual test, required under NFPA 101 sections 19.2.9.1 and 7.9, were not available. This deficiency was cited as affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to perform and/or document required annual testing and exercising of main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During record review, no documentation could be produced to show that the annual breaker exercises had been completed, and the Director of Facilities acknowledged this lack of records. This deficiency relates to the essential electrical system that supports life safety and critical branches during emergencies.
Surveyors observed that an adapter was used to power a refrigerator in the kitchen and a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities confirmed both uses, which did not comply with NFPA 99 and NFPA 70 requirements prohibiting adapters and power strips from being used as substitutes for permanent wiring.
Surveyors found that food service operations failed to meet professional food safety standards in both the main and satellite kitchens. In the main kitchen, a cook’s facial hair was not fully covered, the handwashing sink did not initially provide warm water, wet-nested pans and dirty plate domes were stored for use, ice buckets were stained with mold-like discoloration, and the high-temp dishwasher failed to reach the required sanitizing temperature. In the satellite pantry, the dishwasher did not reach required wash temperatures, vents and cabinets above serving dishes had mold-like buildup and residue, floors were damaged and soiled, the dishwasher chemical cabinet was rusted, the AC filter was heavily soiled, the juice dispenser had debris near clean cups, and tray carts contained dirty sheet trays. During tray line observation, salad items were held above 41°F, and a pureed vegetable listed on the menu extension was not available on the line.
Two residents on physician-ordered modified diets (pureed and mechanical soft with nectar-thick liquids) were given Regular Menus listing items such as fresh fruit, salad greens, and grilled cheese that were not compatible with their diet orders. Both residents selected items from these Regular Menus, but the facility either could not provide the chosen foods due to diet restrictions or substituted different items (e.g., canned peach halves instead of fresh fruit), despite the residents’ expressed preferences. The RD and dietetic technician confirmed that Regular Menus were routinely provided to all residents, including those on mechanically altered diets, leading to menu choices that did not align with ordered diet consistencies.
Surveyors found that the facility did not follow physician-ordered therapeutic diets or provide prescribed Magic Cup nutritional supplements for several cognitively impaired residents. A resident on a pureed diet with honey-thick liquids was served a lunch without the ordered pureed vegetable, and tray line review on another day showed no pureed vegetables available despite the menu specifying them. Multiple residents with orders for Magic Cup supplements had these listed on their meal tickets but were instead served other desserts or received no supplement at all, while documentation on the MAR indicated full consumption. Dietary staff acknowledged responsibility for providing Magic Cups but could not explain why residents in the dining room did not receive them.
A resident with intact cognition and multiple cardiac and pulmonary diagnoses had clearly documented DNR orders, including signed advance directive forms and care plan entries confirming her wish to avoid resuscitation. During a cardiac emergency, a CNA found the resident unresponsive and notified an RN, who initiated a code blue response. Several RNs and LPNs transferred the resident to bed and began CPR without first verifying code status, despite one LPN asking and then leaving the room to check the record. Staff interviews and video review showed that chest compressions and use of a bag-valve mask continued for about 12 minutes until EMS arrived, even after staff learned the resident was DNR, and the physician confirmed the resident was already listed as DNR in the system, leading to an Immediate Jeopardy finding for failure to honor advance directives.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Improper Use of Power Strip as Permanent Power Source in Electrical Room
Penalty
Summary
Surveyors identified a deficiency related to improper use of relocatable power taps (RPTs) and power strips in violation of NFPA 99, NFPA 70, and NFPA 1 requirements. During a facility tour conducted between 10:00 a.m. and 12:00 p.m. with the Maintenance Director, surveyors observed one power strip in the electrical room being used as a source of permanent power instead of being connected to a dedicated receptacle. The report notes that this use did not comply with standards that require extension cords and power strips not be used as a substitute for fixed wiring and that they be used only under specified conditions. The deficiency specifically concerns the facility’s failure to ensure that RPTs are maintained and used in accordance with NFPA 99 (2012 Edition) sections 10.2.3.6 and 10.2.4, and NFPA 70 (2011 and 2020 Editions) provisions governing flexible cords and temporary wiring, as well as NFPA 1 (2021 Edition) sections 11.1.2.2, 11.1.4.1, and 1.4.1. The report states that this condition could lead to electric hazards for residents and staff. No individual resident cases, medical histories, or specific clinical conditions are described in connection with this deficiency.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Facility wide audit of electrical rooms was conducted to identify improper use of power strips. No additional concerns were identified. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; The facility completed education reinforcing compliance with electrical safety requirements in accordance with National Fire Protection Association. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete random electrical safety audits 2 times per week for 4 weeks, then monthly to ensure compliance with electrical safety standards. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Document Required Annual 90‑Minute Emergency Lighting Test
Penalty
Summary
Surveyors identified a deficiency related to emergency lighting when, during record review and staff interview between 11:30 AM and 3:00 PM with the Director of Facilities, the facility was unable to provide documentation that the required annual 90‑minute testing of emergency lighting had been performed. The Director of Facilities acknowledged that there was no documentation available to show completion of this annual 90‑minute emergency lighting test, as required by NFPA 101 (2012 and 2021 editions), sections 19.2.9.1 and 7.9. This failure to document the annual emergency lighting test was cited as a noncompliance that could affect all occupants of the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report; the deficiency pertains to facility-wide life safety systems and their required testing and documentation.
Plan Of Correction
Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Emergency Lighting CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Emergency Lighting K0291 The facility immediately conducted a comprehensive inspection of all emergency lighting systems. On The Director of Facilities performed the required 90-minute annual testing of all emergency lighting units. Documentation of testing has been completed and is maintained on-site. 2. All areas of the facility were considered at risk due to lack of documented annual testing. A full facility-wide audit of all emergency lighting units was completed on by the Director of Facilities to ensure compliance. 3. The facility implemented a preventative maintenance schedule to ensure annual 90-minute emergency lighting testing is completed in accordance with NFPA 101 (2012), Section 7.9. A log tracking system has been developed to document all required testing. The Director of Facilities/designee will receive re-education on Life Safety Code requirements and documentation standards. 4. The Director of Facilities will review fire alarm testing records quarterly for 12 months, will present the findings for 12 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the twelve months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Perform and Document Annual Main and Feeder Breaker Testing
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual maintenance and testing of the main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation of the annual main and feeder breaker exercise. The facility was unable to provide records demonstrating that this testing and exercising had been completed as required. In interviews conducted during the same time frame, the Director of Facilities acknowledged that the facility did not have documentation showing that the annual main and feeder breaker exercise was performed according to manufacturer recommendations. The report notes that this failure to comply with NFPA 99 (2012 and 2021 editions, Sections 6.4.4 and 6.5.4) could affect all occupants of the facility in the event of a fire or other emergency, and that written records of maintenance and testing are required to be maintained and readily available.
Plan Of Correction
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Systems - Essential Electric System CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Systems - Essential Electric System Maintenance and Testing K0918 1. On A licensed electrical contractor performed the annual main and feeder breaker testing/exercising in accordance with manufacturer recommendations. Documentation has been completed and is maintained on-site. 2. All residents were considered at risk due to lack of documented testing. A full review of the essential electrical system was conducted on . 3. A preventative maintenance program has been implemented to ensure that annual breaker testing is completed per NFPA 99 (2012). The facility has incorporated electrical system testing into its environmental compliance tracking system. The Director of Facilities/designee received re-education on NFPA requirements. 4. The Director of Facilities will audit electrical system maintenance logs quarterly for 12 months. Inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, , and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Improper Use of Adapters and Power Strips for Refrigerators
Penalty
Summary
The deficiency involves improper use of electrical adapters and power strips as substitutes for permanent wiring, in violation of NFPA 99 and NFPA 70 requirements. During an observation with the Director of Facilities, surveyors found that an adapter was being used to power a refrigerator in the kitchen. The Director of Facilities acknowledged that an adapter was in use for this refrigerator, contrary to the standards that prohibit adapters from being used in place of fixed wiring. In a separate observation with the Director of Facilities, surveyors identified that a refrigerator in the dining room manager's office was plugged into a power strip. The Director of Facilities acknowledged that a power strip was being used for this refrigerator. These findings showed that the facility was not complying with NFPA 99 provisions that require power strips and adapters not be used as substitutes for permanent wiring for such equipment.
Plan Of Correction
Formatted text (without <text> tags or quotes): Electrical Equipment - Power and Extension Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that Continued from page occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required. Electrical Equipment - Power and Extension CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Electrical Equipment - Power and Extension K0920 1. On The adapter in the kitchen refrigerator and the power strip in the dining room manager's office were immediately removed. All equipment was plugged directly into approved wall outlets. 2. On A facility-wide inspection was conducted by The Director of Facilities to identify improper use of power strips and adapters. Any non-compliant items were removed immediately. 3. On Staff were educated on proper electrical safety practices, including prohibited use of extension and adapters. Routine environmental rounds now include electrical safety checks. 4. The Director of Facilities/designee will conduct monthly environmental rounds for 3 months, then quarterly thereafter. Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required.
Food Safety and Sanitation Deficiencies in Main and Satellite Kitchens
Penalty
Summary
Surveyors identified multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the main kitchen and a satellite pantry kitchen. In the main kitchen, a cook’s beard cover did not fully cover all facial hair, and the handwashing sink initially did not provide warm water until the Executive Director manually adjusted a valve under the sink. In the pot washing area, full-sized steam table pans were stacked while still wet, and more than five plate domes with stuck-on food particles were found piled in the tray line area ready for use, indicating they had not been properly washed. Two large ice buckets were stained with black and grey mold-like discoloration and white wear marks. The high-temperature dishwashing machine in the main kitchen was run three times but failed to reach the required 180°F rinse temperature, only reaching 172°F, meaning dishes were not properly sanitized. In the second-floor satellite pantry kitchen, the high-temperature dishwashing machine was also run three times and failed to meet required wash temperatures, reaching only 139°F instead of the required 150–165°F, so dishes were not properly cleaned and sanitized. Additional sanitation and maintenance issues were observed, including a vent above serving dishes with a mold-like accumulation, broken and soiled cabinets above serving dishes with residue on the handles, and pantry floors with cracked, broken, and missing tiles with debris or residue buildup. The dishwasher chemical cabinet lock was rust-laden, the AC filter was covered with dark grey soot and dust, the juice dispenser with clean cups nearby had debris on top, and tray delivery carts contained large sheet trays with residue and stuck-on food debris. During a tray line observation, chopped tomatoes and sliced avocados on the salad line were held at 44°F and 45°F respectively, above the required 41°F or less, and the menu extension listed pureed peas for a pureed diet, but no pureed vegetable was present on the line.
Plan Of Correction
Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0812 1. All identified sanitation issues were corrected on Hot water valve was fixed immediately by maintenance team Steam table pan wet nesting was corrected The 5 plate domes that were dirty were taken to the dishwasher to be washed Stained ice buckets were replaced with new ones Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day Team member was provided education and in-service on proper use of beard guard. Corrected on [R] 2.Identified issues from satellite Kitchen were corrected on [R] Dishwashing machine not reaching temperature for rinse cycle was fixed by Eco lab the same day The vent located above the serving dishes was cleaned by maintenance team The cabinets were cleaned immediately The floors of the pantry area were observed with broken, cracked, missing tiles, with buildup residue and debris. Maintenance director made aware in the process of getting replaced. The locking mechanism of the dishwasher chemical cabinet is rust laden. Laden removed and in the process of being replaced. The AC filter was cleaned by maintenance team Th juice dispenser was cleaned by dietary aide The large delivery trays with residue and food debris were discarded 3. Issues identified during Tray line observation were corrected: The chopped tomatoes and sliced avocados were discarded Pureed vegetable was added to the line. Inservice on serving all food groups, starches, protein and vegetables to residents on texture modified diet order. Inservice provided to all dietary aides Inservice on maintaining and holding temperatures for ready to eat foods. Inservice provided to all cooks and dietary aides Daily sanitation rounds will be conducted by the Certified Dietary manager /designee for one week. Weekly for 2 months. 4. The Certified Dietary Manager/Executive Chef/designee will report the findings of the above observations and audits to the monthly QAPI Committee. The Administrator is responsible for confirming implementation and compliance of this POC and and resolving any variances that may occur.
Failure to Honor Diet-Appropriate Menu Choices for Residents on Modified Diets
Penalty
Summary
The facility failed to provide residents with menu choices that matched their physician-ordered diet textures and liquid consistencies. One resident with severe cognitive impairment had a physician order for a controlled diet with pureed texture and honey-thick liquids. During a noon meal observation, this resident’s meal ticket was stapled to a Regular Menu listing items such as lettuce and tomato salad, stir-fried vegetables, and a grilled cheese sandwich, none of which were appropriate for the resident’s ordered diet. The Registered Dietitian and the Dietetic Technician confirmed that Daily Menu printouts with Regular Menu options were provided to all residents, including those on mechanically altered diets, resulting in residents being offered choices that could not be honored due to diet restrictions. Another resident with moderate cognitive impairment had a physician order for a mechanical soft diet with nectar-thick liquids. This resident’s lunch tray ticket was also stapled to a Regular Menu that included salad greens, which are not allowed on a mechanical soft diet. On a separate breakfast observation, the same resident’s Regular Menu included fresh fruit as a choice, which the resident circled, but the tray contained canned peach halves instead. The resident stated she wanted her chosen fresh fruit rather than the peaches and reiterated her food preferences during the interview. Photographic evidence was obtained to document these discrepancies between ordered diets, menu offerings, and the food actually provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is requiredF05501. Resident #54 and Resident #56 were immediately assessed by the Registered Dietitian (RD) & CDM (Certified Dietary Manager) for food preferences on Residents #54 and #56 were offered meal choices consistent with the prescribed diet. No adverse outcomes were identified. 2. 100% audit of all residents with therapeutic diets was completed on [R] by CDM to ensure menus and meal selections consistent with physician-ordered diets.On [R] , CDM provided in-service provided to dietary aides, certified nursing assistants, nurses, managers on new selective menu processes. 3. The facility implemented a diet-specific menu system and pre-meal diet verification process by reviewing the diet in tray ticket program IMPAC and PCC. Copies of the menus to be provided as part of the audits.Diet Menu was revised to include a mechanically altered diet to be consistent with physician orders. Therapeutic diets menus are available and offered to each resident according to physician orders. The Dietary Manager or designee will conduct weekly audits of 4 residents on therapeutic diets x 4 weeks then monthly x 2months, to verify the correct menu is offered and served. 4. The Dietary Manager or designee will report findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R] , and resolving any variances that occur.
Failure to Follow Therapeutic Diet Orders and Provide Prescribed Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and prescribed nutritional supplements for multiple residents. One resident with severe cognitive impairment and a physician’s order for a controlled diet with pureed texture and honey-thick liquids was observed at lunch without the ordered pureed vegetable; her plate contained only pureed chicken, a pureed starch, and possibly a pureed bread, all covered in gravy. The pureed menu for that meal listed broccoli as the vegetable, and a subsequent tray line observation on another day showed no pureed vegetables available, despite the pureed menu specifying pureed peas. The dietary manager and registered dietitian were informed of the missing pureed vegetables, and photographic evidence was obtained. The facility also failed to provide ordered Magic Cup nutritional supplements as prescribed. One resident with severe cognitive impairment and a care plan addressing risk for compromised nutritional status had a physician’s order for a 4 oz Magic Cup on day and evening shifts with lunch and dinner; during a breakfast observation, the meal ticket listed Magic Cup, but none was provided. Another resident with moderate cognitive impairment had a physician’s order for a 4 oz Magic Cup with lunch; during lunch observation, the meal ticket indicated Magic Cup, but the resident was served chocolate ice cream and ate coconut cream pie for dessert instead. The MAR documented 100% consumption of a Magic Cup on two consecutive days, despite the observed failure to provide it. During interviews, the RD and dietary manager explained that Magic Cups were to be provided by dietary staff either on trays or via the dessert/ice cream cart, but they could not explain why residents in the dining room did not receive the ordered supplements. Photographic evidence was obtained of these occurrences.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required F0803 1. Upon identification, resident #54 was given pureed vegetables. Residents #23, #39, and #54 were given Magic Cup supplements as ordered. On [R] CDM re-educated team members on supplement delivery including proper documentation and confirming that pureed diet being served matches what is listed on spread sheet. Dietary aides' morning and evening shifts are accountable for serving all food groups including vegetables when serving puree meals to residents. 2. A 100% audit of all residents with therapeutic diets and/or supplements was completed on [R] by Certified Dietary Manager. 3. A tray line checklist and diet/supplement reconciliation process between dietary and nursing were implemented by [R]. RD oversight of menu compliance was initiated. The Certified Dietary Manager or designee will audit food tray weekly x 4 weeks then weekly x 2 months. 4. The Certified Dietary Manager/Designee will report on the findings at the monthly QAPI meeting. The Administrator is responsible for confirming implementation and compliance with this POC and [R], and resolving any variances that may occur.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.
Removal Plan
- Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
- Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
- Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
- Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
- Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
- Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
- Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
- Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
- Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
- Conducted a 100% audit of all current residents’ code status and care plans.
- Conducted a 100% audit of crash carts to ensure all required items were present.
- Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
- Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
- Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
- Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
- Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
- Completed honoring advance directives attestation with licensed nursing staff.
- Completed physician orders education for licensed nursing staff.
- Completed medical emergency response and communication of code status education for licensed nursing staff.
- Completed ANE/Resident Rights education for all staff.
- Completed advance directives posttest for licensed staff.
- Completed ANE/Resident Rights posttest for all staff.
- Completed code blue process/"It Takes Two" education for licensed nursing staff.
- Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
- Completed CNA roles-in-code-blue training.
- Completed quality reviews validating staff competencies for completed education.
- Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
- Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.
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